CLINICAL REPORT

Fabrication of a screw-retained restoration avoiding the facial

access hole: A clinical report
Sabrina Garcia-Gazaui, DDS,a Michael Razzoog, DDS, MS, MPH,b Marianella Sierraalta, DDS, MS,c and
Berna Saglik, DDS, MSd
Implant screw-retained resABSTRACT
torations are not usually
Dental implant restorations may be either screw-retained or cemented onto an abutment. While
considered as the rst method
each method has its advantages and disadvantages, cemented restorations are commonly used in
of rehabilitation because esthe maxillary arch, usually because of esthetic concerns. Available bone in the anterior maxilla
thetics may be compromised.
dictates the placement of the implant, which may result in a facially positioned screw-access
Esthetics are dependent largely
opening. Still, a growing volume of literature states that periimplant soft tissues respond more
favorably to screw-retained crowns than cement-retained crowns. This clinical report outlines a
on patient selection and the
treatment with a new method of fabricating a custom abutment-crown combination for a screwtype and volume of the tissue
retained restoration. The technique allows the channel for the screw to be placed at an angle
surrounding the implant and
other than parallel to the implant body. In this case, the practitioner may choose either a screwimplant position. The retention
retained or cement-retained implant restoration, where previously only a cemented restoration
of the implant crown is typiwas possible. (J Prosthet Dent 2015;114:621-624)
cally determined by clinician
preference.1-3 Screw-retained restorations are easier to
retrieve and may be easier to maintain. However, screw
retention may not be an option where the screw access is
visible. Cement-retained restorations accommodate more
implant positions and are widely preferred.4 An angulated
screw channel (ASC) abutment, where the screw access
can be placed with an angle of up to 25 degrees from the
axis of the implant anywhere within a 360-degree radius,
has been recently developed by Nobel Biocare. Avoiding
the facial access hole by using an ASC abutment provides
the benets of fabricating a screw-retained restoration
without sacricing esthetics.
CLINICAL REPORT
A partially edentulous 34-year-old woman with no
relevant medical history presented for a denitive
restoration after implant placement in the site of the

Figure 1. Poorly contoured existing implant interim restoration.

Presented at the American Prosthodontics Society Annual Meeting, Chicago, Ill, February 2015.
a
Resident, Department of Biologic and Material Sciences, Division of Prosthodontics, School of Dentistry, University of Michigan, Ann Arbor, Mich.
b
Director, Department of Biologic and Material Sciences, Division of Prosthodontics, School of Dentistry, University of Michigan, Ann Arbor, Mich.
c
Clinical Professor, Department of Biologic and Material Sciences, Division of Prosthodontics, School of Dentistry, University of Michigan, Ann Arbor, Mich.
d
Clinical Associate Professor, Department of Biologic and Material Sciences, Division of Prosthodontics, School of Dentistry, University of Michigan, Ann Arbor, Mich.

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Figure 2. New implant interim restoration was delivered reproducing

appropriate contours.

Figure 3. Implant position comprises esthetics at facial and incisal aspects of restoration if screw-retained restoration was to be fabricated.
Green cylinder represents screw channel location.

maxillary right lateral incisor. Comprehensive clinical and

radiographic examinations were completed. An existing
implant interim restoration was present; however, in an
effort to avoid a facial screw-access hole (Fig. 1), it did not
conform to the contours of the adjacent teeth. The
existing implant interim restoration was removed, and a
custom impression coping, preserving the sculpted soft
tissue, was fabricated and seated. A denitive impression
was then made with the closed tray technique using
polyvinyl siloxane impression material (Aquasil Ultra
Monophase and XLV; Dentsply Caulk). The denitive
cast, which replicated the developed emergence prole,
was fabricated (Jade Stone; Whip Mix Corp) and was
used to fabricate the interim and denitive restoration. A
THE JOURNAL OF PROSTHETIC DENTISTRY

Figure 4. A, Screw channel, represented by green cylinder, was angled

to 23 degrees (blue arrow) to avoid facial access opening. B, Sagittal
plane of ASC zirconia abutment. Channel widens toward screw head (red
arrow) to allow proper engagement of Omnigrip and special screw.

new interim restoration was fabricated with autopolymerizing acrylic resin (Alike; GC America Inc), trimmed,
nished, and delivered (Fig. 2). The cast was digitized
(NobelProcera 2G System; Nobel Biocare), and an ASC
zirconia custom abutment with a screw channel angulation of 23 degrees from parallel was designed with
3-dimensional imaging software (NobelProcera CAD/
CAM System; Nobel Biocare) (Figs. 3, 4). Design
Garcia-Gazaui et al

November 2015

Figure 5. Frontal view of zirconia ASC abutment during evaluation.

623

Figure 6. Occlusal view of zirconia ASC abutment.

Figure 8. Denitive restoration.

tape (Dixon Valve TTB75 PTFE; Dixon Valve & Coupling

Co) and composite resin (Gradia Direct; GC America Inc)
(Fig. 8).
Figure 7. Omnigrip driver ute design allows screw engagement from
different angles without compromising positioning or abutment
tightening.

information was transferred electronically to the production facility, where the abutment was milled. The
ASC custom abutment was evaluated, the contours
veried, and the restoration shade selected (Figs. 5, 6).
Veneering porcelain was added to the facial aspect to
complete the esthetic portion of the restoration. The
seating of the abutment-crown was conrmed radiographically before tightening the abutment screw to 35
Ncm. The tightening of the special screw was performed
with a special screwdriver (Omnigrip; Nobel Biocare)
with rounded utes to engage the screw (Fig. 7). Patient
approval of the contours and shade was obtained, and
the access hole was sealed with polytetrauoroethylene

Garcia-Gazaui et al

DISCUSSION
When an implant is ideally placed, the clinician may
choose the type of retention. Clinicians should be aware
of the limitations and disadvantages of each type of
prosthesis so they can select the one that is most
appropriate for a given clinical situation. Ideal placement
implies that the screw access hole is not visible and that
the abutment is in the correct spatial relationship to
support an esthetic restoration. When screw retention is
chosen, the abutment should be angled through the
cingulum to allow for a screw access angle that does not
compromise the incisal edge of the restoration. Where
the access hole compromises esthetics, the design of an
ASC abutment permits the screw access hole to be
positioned on the lingual side of the restoration. This
zirconia abutment adapts mechanically to a titanium
metal insert. No cement is needed to connect the

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components. Ease of use is provided by the Omnigrip

tooling, a special driver that allows a unique connection
with the Omnigrip screw. A pick-up function is also a
feature of the driver, increasing safety when handling
the screw. Effective torque can be applied at any angle
from 0 to 25 degrees. Therefore, an esthetic result is
achieved without the risk of excess cement. New technology allows clinicians to offer screw-retained restorations in a practical and esthetic way that previously may
have been impossible.
SUMMARY
A new method of fabricating screw-retained restorations
may be selected as an option when esthetics are
compromised because of the access hole location. The
prosthetic rehabilitation of the maxillary right lateral
incisor where the implant was placed with a facial
inclination was possible with a screw-retained restoration

that features an ASC within the design of the custom

abutment-crown restoration.
REFERENCES
1. Chee W, Jivraj S. Screw versus cemented implant supported restorations. Br
Dent J 2006;201:501-7.
2. Dario LJ. Implant angulation and position and screw or cement retention:
clinical guidelines. Implant Dent 1996;5:101-4.
3. Michalakis KX, Hirayama H, Gares PD. Cement-retained versus screwretained implant restorations: a critical review. Int J Oral Maxillofac Implants
2003;18:719-28.
4. Hebel KS, Gajjar RC. Cement-retained versus screw-retained implant restorations: achieving optimal occlusion and aesthetics in implant dentistry.
J Prosthet Dent 1997;77:28-35.
Corresponding author:
Dr Sabrina Garcia-Gazaui
University of Michigan
1011 N University Ave, Rm 1378
Ann Arbor, MI 48109
Email: samireth@umich.edu
Copyright 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

Noteworthy Abstracts of the Current Literature

Association between oral mucosal lesions and hygiene habits in a population
of removable prosthesis wearers
Ercalik-Yalcinkaya S, zcan M
J Prosthodont 2015:24:271-278
Purpose. This prospective study evaluated the inuence of self-reported prosthesis hygiene regimens and prosthesis
usage habits on the presence of oral mucosal lesions (OMLs) in complete removable and/or partial removable dental
(CRDP/PRDP) prosthesis wearers (PWs).
Materials and methods. Between January 2009 and January 2011, the conventional oral mucosa of 400 consecutive
PWs (252 women; 148 men), aged between 29 and 86 years, were examined clinically. Information was derived
considering the type and age of the prosthesis, hygiene level, frequency and style of prosthesis cleaning, overnight
prosthesis use, storage conditions, and systemic diseases. Non-prosthesis- and prosthesis-related OMLs were identied. The data were analyzed using univariate (Chi-square) and multivariate (logistic regression) tests to assess the
development of OMLs as a function of the selected variables. Odds ratios (OR) were calculated at 95% condence
intervals (CI; a = 0.05).
Results. Of the 400 PWs, 21.5% had CRDP, 52.5% PRDP, and 25.8% CRD/PRD prostheses. Thirty-two percent of the
PWs cleaned their prosthesis once a day. Brushing the prosthesis with toothbrush and soap/toothpaste was the most
commonly practiced cleaning regimen (85.8%). More than half (64.5%) of the PWs used their prosthesis overnight.
Among all PWs, 37.8% had a prosthesis-related OML. Stomatitis Newton Type II (46%) and Type III (38%) were the
most common OMLs. OML frequency was higher in PWs having CRDPs than those having PRDPs (p < 0.05).
Overnight prosthesis use (p = 0.003, OR: 13.65; 95% CI: 1.7e109.3), denture age 11 years (p = 0.017, OR: 1.72; 95%
CI: 1.1e2.7), and immersion in water and solution (p = 0.023, OR: 1.13; 95% CI: 0.02e1.02) affected the incidence of
OML signicantly. Hypertension was the most common systemic disease (31.5%).
Conclusion. Overnight use, denture age, and storage conditions of CRDP or PRDPs demonstrated a more signicant
impact on OML incidence than frequency of cleaning. Oral healthcare programs for removable PWs should specically
provide education on prosthesis usage instructions.
Reprinted with permission of the American College of Prosthodontists.

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